Case presentation:
40 years old male Surgeon came to the clinic presenting with severe gingival enlargement confined to upper and lower anteriors invading labial , palatal & lingual gingiva interfering with mastication , speech and had a poor esthetic impact on the patient.
Due to such enlargement , it created lip incompetence ” no lip seal” during rest position that’s why it caused the patient a mouth breathing habit especially when he is sleeping which aggravates the condition and let the gingiva inflamed.
Medical history reveals that the patient is under immunosuppressive drug therapy since 1 year which is cyclosporine which is taken as result of organ transplantation surgery was done which was kidney transplantation.
Cyclosporine is taken here to inhibit any immune reaction against the grafted organ to prevent graft rejection.
Clinically it had a mixed color ” pale pink with some erythematous areas” in which there is bleeding on probing while pure pink areas dont bleed on probing……
Local factors including plaque and calculus harbored these enlargements which acted as a recevoir for food impaction compromising oral hygiene measures to the patient.
So , it is a drug induced enlargement superimposed by inflammatory one ” Mixed enlargement” and there are 2 factors causing the gingival enlargement now:-
1-Cyclosporine.
2-Local irritating factors (e.x: plaque & calculus)
Treatment plan includes:
1-Full mouth scaling and root planning to remove local irritants. (for 3 visits)
2-Consultation with the phyisican if there is any possibility for drug replacement with another one that doesn’t induce enlargement which was forbidden as the systemic condition of the patient doent allow for its replacement and it is highly recommended.
3-Gingival size decreased a little bit after scaling and root planning nd become more fibrous and all erythematous areas are resolved but it still enlarged due to cyclosporine.
4-Gingivectomy was put in plan to improve quality of oral hygiene although it will recur due to the drug effect but care follow up and strict instructions to follow oral hygiene measures will be taken and periodic follow up every 3 months was planned to prevent any further inflammatory reaction.
5-Systemically the patient had reached the stable post-transplantation stage after consultaation with the treating phyician,,,,,which necessitates a prophylactic antibiotic “minimum 5 days before the surgery” to avoid any infection…..also Diclofenac sodium & potassium are contraindicated to be prescribed as they may decrease levels of immunosuppressive drug and also may affect the grafted kidney.
6-Lab investigations like CBC , bleeding & clotting times , INR was demanded from the patient before surgery which were within normal.
7-External bevel gingivectomy was done on labial and lingual mucosa…….full details of the surgery will be included in the surgery video with illustrations”
8-Periodontal dressing was applied over the wound labially and lingually to avoid contamination and accelerate healing.
9-Following 2 weeks , complete healing was found with complete re-epithelization.
10-After these 2 weeks , the surgery for upper anteriors preformed was done with the same precautions
case is still under follow-up till now every 3 months
Occlusal view revealing enlargement in both aspects “labial and lingual” with local irritants stagnated in between
Also some gingival margins are lacerated and inflamed as a response to local irritants
Occlusal view revealing enlargement in both aspects “labial and lingual” with local irritants stagnated in between
Also some gingival margins are lacerated and inflamed as a response to local irritants
The above photo was after 3 visits of Scaling and root planning, small shrinkage in gingival size is observed, no erythema and lobulation of the gingiva was also noted
Occlusal l view showing the same response after scaling and root planning 3 visits (about 3 weeks)
Immediately post surgical photo
“Labial view”
Immediately post surgical photo
” Occlusal view “
Periodontal dressing application over the wound labially and lingually to avoid contamination during healing phase
Final healing following 2 weeks
“Labial view”
Final healing following 2 weeks
“Occlusal view”
The below photo showed shrinkage of the gingival size after curettage for 3 visits as done for lower anteriors..
Occlusal view following scaling and curettage with lobulation of the gingiva
Immediately post surgical photo
“labial view”
Immediately post surgical photo
“occlusal view”
Following 2 weeks postoperative healing with restoration of the gingival texture and shape
Occlusal view
Before & after
before treatment , gingival enlargement for upper anterior teeth was elevating the upper lip during smile causing some sort of gummy smile….also it was preventing normal competent lips causing a mouth breathing habit which aggravates the inflammatory condition
finally the patient can smile normally with confidence after complete healing… And there is no more mouth breathing habit.
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